Intermittent Steroid Use Called OK for Wheezing Preschoolers

WEDNESDAY, Nov. 23 -- Preschoolers who have recurrent wheezing episodes but not an asthma diagnosis are often prescribed inhaled steroid medication, and new research suggests it's OK to take those medications on an as-needed basis instead of every day.

Respiratory illnesses frequently trigger severe wheezing in young children, and the treatment for some of these kids -- using inhaled steroid medications such as budesonide (Pulmicort) on a daily basis -- might expose them to more of the drugs than necessary, the researchers said.

"We learned that the daily, low-dose treatment regimen of inhaled budesonide was no better than a high-dose regimen used for seven days during a specific respiratory illness," said the study's lead author, Dr. Robert Zeiger, a clinical professor of pediatrics at the University of California, San Diego, and director of allergy research at Kaiser Permanente in San Diego.

"However, there are certain caveats to the findings. This is only applicable to patients similar to those studied. It would not be applicable to those with more severe wheezing episodes or those with persistent wheezing. And, parents shouldn't institute treatment for every sniffle or cold. Parents need to be instructed on when to use the treatment. They'll need to recognize past symptoms that preceded the development of a wheezing episode," Zeiger explained.

Results of the study are published in the Nov. 24 issue of the New England Journal of Medicine. Funding for the study was provided by the U.S. National Heart, Lung, and Blood Institute and several academic institutions.

Daily use of inhaled budesonide is recommended for children under 5 years who've had four or more wheezing episodes during the past year, and have an increased risk of developing asthma.

"These are toddlers at high risk for asthma, but they don't have persistent symptoms. Persistent means more than twice a week. When these kids get sick, they often get very sick with respiratory symptoms," said Dr. Shean Aujla, a pediatric pulmonologist at Children's Hospital of Pittsburgh.

While inhaled steroid medications have considerably fewer side effects than steroids taken orally, there's still concern when using any medication in the long term in children. Previous research has suggested that long-term use of inhaled corticosteroids may cause a small reduction in a child's height.

The new study sought to assess whether or not less frequent administration of inhaled steroids, but at higher doses than prescribed for daily use, would be effective.

The researchers included 278 children between the ages of 12 and 53 months (1 to 4-plus years). All of the children had a high risk of developing asthma, had recurrent wheezing episodes, and had experienced at least one wheezing episode in the past year, according to the study.

For one year, the children were randomly assigned to receive either daily treatment with 0.5 milligrams (mg) of inhaled budesonide or 1 mg twice daily for seven days at the start of a respiratory illness similar to one that caused wheezing in the past.

They found no difference between the groups for the number of wheezing episodes, the time to the first wheezing episodes or the occurrence of adverse side effects. Children in the intermittent treatment group received 104 milligrams less medication over a year than children in the daily use group, according to the study.

"This study showed that in this particular population, there was no difference in using intermittent budesonide compared to daily," Aujla said.

"We see this population a lot, and they're a challenge to treat. They may only have symptoms in the winter, or when they have a cold, and many families are concerned about using medication every day," she added.

Zeiger said the intermittent use of budesonide will likely be more convenient for parents and children, but parents "should never take wheezing lightly," he cautioned. "It can lead to severe exacerbations, ER visits and hospitalizations. Parents should seek care for a child who has frequent wheezing episodes because we have therapies that can reduce the burden of the child's illness."